NRSG 780: Health Promotion and Population Health Essay

Abstract

Among the most prominent problems that are of public health, the concern is opioid overdose in the USA. The adverse impacts, such as increased death rates, have made the problem attract considerable attention. Baltimore city is one of the places with the highest mortality rates resulting from an opioid overdose. Effective programs should be formulated to help solve the problem. The implementation of such problems requires that the individuals involved are brought on board. Another important aspect is the creation of various aspects of such a program. This write-up has covered various aspects such as goals and objectives and the program planning. The MAP-IT model has been used as the planning model, while the transtheoretical framework has been proposed for the implementation.

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Opioid overdose is one of the most common problems affecting individuals in the US. The problems led to a considerable number of deaths every year. More worryingly, the problem has been on an upward trend in recent years (Hodder et al., 2022). One of the places that have the highest cases of opioid overdose is Baltimore city. Among Baltimore city residents that died from a drug overdose, 435 deaths (65%) were between 45-64 years of age. Fifteen deaths (2%) ranged from 25-to 34 years old, leaving a small group under 25 years of age to die due to drug overdose. The 45-54 age group had the highest fatal drug overdose rate, and the ages 55-64 had the biggest increase between 2017-2018 (Irwin et al., 2017). The implication is that population-based programs should be formulated to help reduce mortality and morbidity rates. Therefore, the purpose of this assignment is to design a population-based program to reduce mobility or mortality. The program will incorporate social/behavioral change and program planning frameworks.

The Program Goal and Objectives

The main goal of the program is to reduce mortality rates caused by opioid overdose. To accomplish this overall goal. The following objectives will be used.

To increase public awareness through community and population-based opioid overdose campaigns.
To reduce the stigma surrounding opioid overdose so that those who are affected can come forth to seek help.

Train individuals on how to best respond to the community members who may be experiencing an opioid overdose.

To improve the community strategies and access to opioid misuse treatment and recovery services.
To enhance opioid prescribing practices through collaboration with healthcare providers.
Improving public education and community-based program to reduce and prevent the misuse of opioids.

The program plan

The success of any program heavily hinges on the nature of planning. As such, a comprehensive plan should be put in place to help in the implementation of the proposed program. Therefore, this program plan will explore various aspects.

The program planning model

Models are key in planning, implementing, and evaluating health improvement and promotion programs. Therefore, the chosen model is the MAP-IT model. This model has five major phases including; mobilize, assess, plan, implement and track. The mobilize phase will entail brainstorming potential partners and recruiting coalition members can create a vision (Hansen et al., 2017). Assess phase will involve data collection, the most important issues, identifying community needs, and prioritization. The planning phase involves setting objectives. The implementation phase entails the identification of individuals to coordinate the implementation and inform the community about the initiative. The final phase, which is the track phase, entails evaluation and monitoring.

Activities Identified to Achieve the Objectives

Various activities will be undertaken to help achieve the objectives. One of them is holding community seminars to train the community members on the dangers of opioid overdose and what needs to be done to help in controlling the same. Campaigns will also be undertaken to create awareness. The professionals engaged in the opioid overdose fight will also be encouraged to participate more and use their expertise to help solve the problem. Policy advocacy will also be undertaken to influence the stand of opinion leaders and legislators to support initiatives that can be used to fight opioid overdose better (Painter, 2017). These activities have the potential to ensure the mortality rates caused by opioid overdose.

The Implementation Strategies

Implementation is one of the key phases of a program design. Therefore, it is important to come up with robust implementation strategies that can help or can be key in supporting the effective implementation of the project (Fernandez et al., 2019). One of the strategies is to embrace partnership and collaboration with both internal and external stakeholders. This strategy will ensure that there is a widespread buy-in and improve the chances of the program making the biggest impact possible. The next strategy will be to align the activities with the community stakeholder organizations. This will ensure that there is an alignment of goals hence spurring successful implementation. The other strategy is adaptation and tailoring programs and activities to the context. It is important to align the activities and programs to the context to improve the chances of successful implementation.

Behavior/Social Change Framework

The change framework chosen is the transtheoretical model. According to this model, behavior change plays a critical role in the readiness to undertake and sustain behavior changes (Prochaska, 2020). Therefore, it can be used in those initiatives that focus on people’s ability, motivation, and readiness. This model has five major stages, including pre-contemplation, contemplation, preparation, action, and maintenance. As indicated earlier, one of the plans is to establish a long-term rehabilitation center. Therefore, this model will come in handy to help in the process.

The pre-contemplation stage is a phase where a person shows no intention of changing behaviors due to a possible lack of sufficient knowledge or previous failures in initiating change. The contemplation stage is the phase where an individual considers a change within six months, but they are still held back by ambivalence (Prochaska, 2020). In the preparation stage, the person then takes steps to make the change. In addition, the action stage entails the apparent behavior change, while maintenance entails sticking to the behaviors. Therefore, this model will be key in helping those who experience opioid overdose to deal with the problem.

Collaboration with Existing Services/Organizations

Collaboration is key in ensuring that a program succeeds. Therefore, it is part of the plan to collaborate with existing services. One of the entities identified for collaboration is the Baltimore City Health Department which has been focusing on preventing overdose deaths using a triple-pronged strategy. The strategies include saving lives with naloxone, increasing access to evidence-based treatment, and fighting the addiction stigma.

Evaluation

Program evaluation is key as it helps in knowing the extent of the success of both the methods applied in the intervention and the outcomes (Issel et al., 2021). Therefore, this population-based program will be evaluated using various evaluation strategies. The program will be evaluated by comparing the data on opioid overdose in Baltimore city before the program and after the implementation program. Various steps will be followed to ensure there is a good evaluation. Some of such strategies include engaging the stakeholders, describing the program, focusing on evaluation, evidence gathering, and sharing and applying the lessons learned.

Conclusion

Opioid overdose is a major health concern as it leads to many cases of death. Therefore, this write-up has proposed a population-based program that can be used to reduce mortality rates due to opioid overdose. Various objectives have been formulated that are to act as the guide to the program.

References

Fernandez, M. E., Ten Hoor, G. A., Van Lieshout, S., Rodriguez, S. A., Beidas, R. S., Parcel, G., … & Kok, G. (2019). Implementation mapping: using intervention mapping to develop implementation strategies. Frontiers In Public Health, 7, 158. https://doi.org/10.3389/fpubh.2019.00158

Hansen, S., Kanning, M., Lauer, R., Steinacker, J. M., & Schlicht, W. (2017). MAP-IT: a practical tool for planning complex behavior modification interventions. Health Promotion Practice, 18(5), 696-705. https://dx.doi.org/10.1177%2F1524839917710454

Hodder, S. L., Feinberg, J., Strathdee, S. A., Shoptaw, S., Altice, F. L., Ortenzio, L., & Beyrer, C. (2021). The opioid crisis and HIV in the USA: deadly synergies. The Lancet, 397(10279), 1139-1150. https://doi.org/10.1016/S0140-6736(21)00391-3

Irwin, A., Jozaghi, E., Weir, B. W., Allen, S. T., Lindsay, A., & Sherman, S. G. (2017, May 12). Mitigating the heroin crisis in Baltimore, MD, USA: A cost-benefit analysis of a hypothetical supervised injection facility – harm reduction journal. BioMed Central. Retrieved March 7, 2022, from https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0153-2

Issel, L. M., Wells, R., & Williams, M. (2021). Health Program Planning and Evaluation: A Practical Systematic Approach to Community Health. Jones & Bartlett Learning.

Painter, S. G. (2017). Opiate crisis and healthcare reform in America: A review for nurses. OJIN: The Online Journal of Issues in Nursing, 22(2). https://doi.org/10.3912/OJIN.Vol22No02Man03.

Prochaska, J. O. (2020). Transtheoretical model of behavior change. In Encyclopedia of behavioral medicine (pp. 2266-2270). Cham: Springer International Publishing. Doi: 10.1007/978-3-030-39903-0_70

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NRSG 780
Module 8: Program Planning Essentials and Models
OVERVIEW
The purpose of this module is to provide an overview of the core functions of public health and the public health system, to examine the key elements of effectiveness-based program planning and to introduce population-based program planning models.
Objectives
At the conclusion of this module, the learner will be able to:
● Explain the core functions of public health
● Describe key components of the public health system
● Distinguish the essential components of effectiveness-based program planning
● Utilize program planning models to develop effective interventions
Required Readings
● Office of Disease Prevention and Health Promotion (DHHS). (2014). Program Planning: MAP-IT: A Guide to Using Healthy People 2020 in Your Community.
● W.K. Kellogg Foundation. (2004). Logic Model Development Guide, Chapter 1 (pp. 1-14).
● Centers for Disease Control and Prevention (CDC). (2021). 10 Essential Public Health Services.
Recommended Readings
● PRECEDE/PROCEED Section 2. (2014). In Community Tool Box (UK): Learn a Skill.
● Public health interventions: The Minnesota Wheel 2nd edition (2020)The Wheel Manual
Directions
Read the module content and activities. Then complete the assignment for the module
Module Components – Overview | Assignments
CORE FUNCTIONS AND THE PUBLIC HEALTH SYSTEM
Definition of Public Health:
“What we as a society do collectively to assure the conditions in which people can be healthy”
Institute of Medicine Report “The Future of Public Health,” 1988
Exercise
Watch this video to learn more about public health’s role in improving the health status of the United States to in one generation.
Consider the following questions: (click on the question to see the answer)
● Do you think that this video is effective?
● What is missing in this video?
P5 – A Public Health Approach
Five key elements in a public health approach to addressing population health issues:
1. Populations
Target for intervention: the country as a whole; a specific state, county, city, neighborhood or specific group such as people at risk or with a particular disease
2. Prevention
Prevention Levels
○ Primary
○ Secondary
○ Tertiary
3. Prevention Strategies
High-risk: focuses on identifying the relatively small number of individuals who are at high risk in order to reduce their risk factor(s) and subsequent development of disease
Population-based: focuses on changing behavior in large numbers of people, most of whom have low or no risk at present, in order to prevent the development of risk factors and disease
4. Partnerships
○ Activities undertaken within the formal structure of government
○ Associated efforts of private and voluntary organizations and individuals
5. Priorities
Resources are limited, therefore priorities must be established
6. Public Health Workforce
○ A competent public health and personal health care workforce requires:
■ Providing education and training for personnel
■ Licensing professionals and certifying facilities including regular verification and inspection follow-ups
■ Continuing quality improvement and life-long learning within all licensure/certification programs
■ Partnering with professional training programs to assure community-relevant learning experiences
■ Assuring continuing education in management and leadership for administrators and executives
Public Health Obligations of Government
1. Prevent epidemics and the spread of disease
2. Protect against environmental hazards
3. Prevent injuries
4. Promote and encourage healthy behaviors
5. Respond to disasters and assist communities in recovery
6. Assure the quality and accessibility of health services
Core Functions of Government in Public Health
● Assessment—identification of problems
● Policy Development—mobilization of necessary efforts and resources
● Assurance—vital conditions are in place so that crucial services can be received

Source: https://www.cdc.gov/publichealthgateway/images/publichealthservices/10-essential-public-health-services.jpg?noicon
Assessment
1. Assess and monitor population health
2. Investigate, diagnose, and address health hazards and root causes
Policy Development
3. Communicate effectively to inform and educate
4. Strengthen, support, and mobilize communities and partnerships
5. Create, champion, and implement policies, plans, and laws
6. Utilize legal and regulatory actions
Assurance
7. Enable equitable access
8. Build a diverse and skilled workforce
9. Improve and innovate through evaluation, research, and quality improvement
10. Build and maintain a strong organizational infrastructure for public health
The Public Health System

● THE SYSTEM BACKBONE: Governmental Public Health Infrastructure
● Community
● Health care delivery system
● Employers and Business
● The Media
● Academia (public health and health sciences)
Partnerships are expanding in public health and the system is growing more complex as we tackle new problems.

Public health systems are commonly defined as “all public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.” This concept ensures that all entities’ contributions to the health and well-being of the community or state are recognized in assessing the provision of public health services.
The public health system includes:
● Public health agencies at state and local levels
● Healthcare provider
● Public safety agencies
● Human service and charity organizations
● Education and youth development organizations
● Recreation and arts-related organizations
● Economic and philanthropic organizations
● Environmental agencies and organizations
EFFECTIVENESS-BASED PROGRAM PLANNING
Beginning in the 1980s and continuing to today, program planning and implementation has been driven by performance accountability. This stems from the fact that many public health and human service programs are funded by tax dollars. Performance accountability has also been embraced by many private sector organizations such as foundations, non-profits and the United Way. Government and private sector funding sources want to know if the programs they support work and if they do not, funds can be redirected.
Effectiveness-based Program Planning has two foci:
Effectiveness: measurable changes occurring in organizations, communities or systems as a result of receiving services
Program: prearranged set of activities designed to achieve defined goals and objectives
Program Planning: Stepwise Process
Program planning is a stepwise process that includes several critical elements.
1. Determine Need
Review quantitative data (morbidity and mortality reports, survey data, information from available utilization databases such as Medicare and Medicaid, insurers, health care agencies, assessing existing resources)
Review qualitative data (information from key stakeholders, focus groups, public forums)
2. Establish a framework for action-Goals and Objectives
Goals
Characteristics of goals:
○ Goals provide a sense of programmatic direction
○ Goals are not necessarily achievable
○ Goals should fit within the mission of the organization that offers the program*
■ * This is very important to consider since most programs are not funded at a level that allows programs to be freestanding.
3. Examples of Goals

○ Attain healthy, thriving lives and well-being free of preventable diseas, disability, injury, and premature death.
○ Eliminate health disparities, achieve health equity, attain health literacy to improve the health and well-being of all.
○ Create social, physical, and economic environments that promote attaining health and well-being for all.
○ Promote healthy development, healthy behaviors, and well-being across all life stages.
○ Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve health and well-being of all.
4.
Objectives
Outcome Objectives identify results (ends) to be achieved by program, such as reduction in incidence and prevalence of the problem in the target population
Process Objectives identify manner (means) in which results will be achieved, identify milestone necessary to achieve outcome objectives, such as offering weekly screening, referral and follow-up programs for a year that will reach 5000 individuals
Characteristics of Objectives:
○ Objectives should be written in clear, unambiguous terms (behavioral language)
○ Objectives should Identify expected results
○ Objectives should identify measurable results
○ Objectives should identify time frame within which results will be achieved
○ Objective should identify achievable results based on technology, knowledge and resources
○ Objectives should identifies parties responsible for results
5. Example of an Outcome Objective:

Mental Health and Mental Disorders
By 2030, increase the proportion of persons with co-occurring substance abuse and mental health disorders who receive treatment for both from 3.4% to 8.2%.
Baseline: 3.4 percent of adults aged 18 years and over with co-occurring substance use disorders and mental health disorders received both mental health care and specialty substance use treatment in 2018
Target: 8.2 percent
Target Setting Method: Minimal statistical significance
Data Source: National Survey on Drug Use and Health (NSDUH), SAMHSA
Activities
Specific tasks that must be completed to achieve process objectives
Common Activities:
○ Health communications
○ Media advocacy
○ Policy actions
○ Initiatives at work, school, health care settings
6. Characteristics of Potential Activities:
○ Effectiveness—evidence that when properly applied, activity can contribute to attaining the objective
○ Reach—potential for activity to reach a large portion of the target population
○ Acceptability—extent to which the target population, general public and relevant agencies finds the activity socially and culturally acceptable
○ Cost—extent to which the activity is economically feasible
○ Public support—extent to which the activity has potential for engendering positive public opinion, support for the initiative or public health and prevention in general
7. Develop Evaluation Plan during program planning

○ Types of Evaluation:
○ Formative/Process—ongoing evaluation to determine if the program is doing what it set out to do (focus on process objectives)
○ Summative/Outcome—evaluation at conclusion of program to assess accomplishments (focus on outcome objectives)
PROGRAM PLANNING MODELS
A wide range of evidence-based program planning models are available to assist you in developing frameworks for community-based population health programs. Using program planning models typically speeds the planning process and assists in identifying essential elements for program success.
This module will highlight three models:
1. MAP-IT, the model for implementing Healthy People 2030
2. Logic models
3. PRECEDE/PROCEED developed by Drs. Larry Green and Marshall Kreuter
There are many others that may assist you including the Communities That Care Model that specifically focused on preventing youth from problem behaviors, the Community Readiness Model that is issue specific and the Healthy Cities/ Healthy Communities Model, a citizen driven framework used extensively in international settings.
MAP-IT: A framework for planning and evaluating public health interventions in a community

Source: https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/map-it/main
MAP-IT has five steps:
1. Mobilize individuals and organizations that care about the health of your community into a coalition.
2. Assess the areas of greatest need in your community, and the strengths and resources that you can tap into to address those areas.
3. Plan your approach: start with a vision of where you want to be as a community; add strategies and action steps to help achieve that vision.
4. Implement your plan using concrete action steps that can be monitored and will make a difference.
5. Track your progress over time.
How do you use MAP-IT?
1. Mobilize
○ Consider what you want coalition partners to do and how the coalition might be organized
○ Brainstorm potential partners
○ Recruit coalition members
○ Create a vision for the coalition
2. Assess
○ Collect locally available data about resources and needs
○ Collect information from public and archival sources.
○ Determine what issues are most important to community residents and key stakeholders
○ Identify community assets, including people, skills, capacity and capacity building, space, organizations and institutions, knowledge, funds, etc.
○ Based on data and community priorities, prioritize needs by consensus
○ Establish baseline data
3. Plan
○ Choose the issue(s) the initiative will work on
○ Set clear objectives
○ For each objective, develop an action plan that includes:
■ A strategy and tactics
■ A timeline with reasonable time targets for each phase of the strategy
■ The responsible parties and their roles and tasks
■ Indicators and/or other measures of progress
4. Implement
○ Identify an individual or organization to serve as the coordinating point for the implementation of the initiative.
○ Make sure that everyone involved knows what’s going on and what everyone else is doing
○ Use the media and other channels to inform the community about the work of the initiative
5. Track
○ Start your evaluation and monitoring at the very beginning of your initiative, if possible
○ Set up a system for gathering data
○ Consider:
■ Data Quality
■ Limitations of self-reported data
■ Data validity and reliability
■ Data availability
○ Organize and analyze data on a regular basis, so that you can make appropriate adjustments in your work as time goes on
○ Share progress and successes with the community
MAP-IT: Additional Resources
● Healthy People 2020, a collaboration between several different organizations with the mission of setting objectives for the health of the nation. They provide the MAP-IT framework for Implementation, as well as many other useful pages, including:
● Organizing a Coalition: Provides a list of important questions to consider before organizing a coalition, in a printable format that allows you to fill out answers to the questions and/or distribute them to a planning group.
● Potential Partners: A checklist that will help you think of all possibilities for potential partners for your effort.
● Prioritizing Issues: An exercise that will assist you in determining which issues it is most important for your effort to undertake.
● Community Assets: A checklist to assist you in determining community assets that are available.
● Measuring Progress: Helpful formulas for quantitatively measuring your progress.

Logic Model
Basically a logic model is a systematic and visual way to present and share your understanding of the relationships among the resources you have to operate your program, the activities you plan, and the changes or results you hope to achieve.

When read from left to right, logic models describe program basics over time from planning through results. Reading a logic model means following the chain of reasoning or “If…then…” statements which connect the program’s parts. The figure below shows how the basic logic model is read.

The purpose of a logic model is to provide stakeholders with a road map describing the sequence of related events connecting the need for the planned program with the program’s desired results. Mapping a proposed program helps you visualize and understand how human and financial investments can contribute to achieving your intended program goals and can lead to program improvements.
PRECEDE/PROCEED MODEL
PRECEDE/PROCEED: A community-oriented participatory model for creating successful community health promotion interventions. It was among the first and is an internationally recognized program planning model for public health.
PRECEDE/PROCEED is designed to prioritize behavioral and environmental objectives
● Identify risk factors
● Differentiate between behavioral and environmental risk factors
● Focus on the factors most likely to achieve program objectives
● Determine the importance of risk factors
● Determine the potential for changeability
● Identify what is most important and most changeable
● Set objectives–who, what, how much, when
PRECEDE-PROCEED: 9 Phases
Five Diagnostic Phases:
1. Social Assessment
2. Epidemiologic Assessment
3. Behavioral and Environmental Assessment
4. Educational and Organizational/Educational Assessment
5. Administrative and Policy Diagnosis
Four Implementation and Evaluation Phases:
6. Implementation
7. Process Evaluation
8. Impact Evaluation
9. Outcome Evaluation

Additional Planning Models

The Community Tool box is a global resource for free information on essential skills for building healthy communities. It offers more than 7,000 pages of practical guidance in creating change and improvement.
The Community Tool Box offers practical resources for your work:
● How-to Guidance – Table of Contents
● Toolkits
● Troubleshooting guide
● Evidence-based practices – promising approaches
Check out the Community Tool Box at http://ctb.ku.edu/en
Module 9: Program Planning: Focus on Behavior Change
OVERVIEW
The purpose of this module is to provide an overview of behavior change models and health communications strategies used to develop and support population-based health promotion programs.
Objectives
At the conclusion of this module, the learner will be able to:
● Discuss health promotion from an ecological perspective
● Describe key components of behavior change theories
● Select appropriate behavior change models
● Illustrate how different types of communication effect health behavior
● Incorporate behavior change models and health communication strategies into program planning and implementation
Required Readings
● National Cancer Institute, U.S. Department of Health and Human Services (DHHS). (2005). Theory at a Glance, Part 2 (pp. 9-33). Available at http://sbccimplementationkits.org/demandrmnch/ikitresources/theory-at-a-glance-a-guide-for-health-promotion-practice-second-edition/
● Kreuter, M., Lezin, N.,Kreuter, M., Green, L. Community health promotion Ideas that work Chapter 5: Theory applied, Sudbury, MA: Jones and Bartlett. Available through HS/HSL Course Reserves in 780 blackboard
● Centers for Disease Control and Prevention. (2022). Gateway to Health Communications and Social Marketing Practice.
● U.S. Department of Health and Human Services (DHHS). The Guide to Community Preventive Services. Available at http://www.thecommunityguide.org/
Recommended Readings
● Centers for Disease Control and Prevention. (2002). CDCynergy Web: Your Guide to Effective Health Communication. Available at http://www.orau.gov/cdcynergy/web/
● Centers for Disease Control and Prevention. (2021). Health Literacy. Available at https://www.cdc.gov/healthliteracy/index.html
Directions
Read the module content and activities. Then complete the assignment for the module.
Module 9: Program Planning: Focus on Behavior Change
BEHAVIOR CHANGE: AN ECOLOGICAL PERSPECTIVE
Effective public health and health promotion programs help maintain and improve health and the well-being and self-sufficiency of individuals, families, organizations and communities. They generally require behavior change at multiple levels. Programs that are most likely to succeed are based on understanding targeted behaviors and their environmental context. Health behavior theory is a key component in the program planning, implementation and evaluation process.
What is a theory?
A set of interrelated concepts, definitions and proposals that present a systematic view of events or situations by specifying relationships among variables to explain or predict events or situations.
Behavior change theories investigate answers to the why, what and how health problems should be addressed.
Health Promotion has an ecological perspective that involves more than educating individuals and the community about health practices. It includes efforts to change organizational behavior and physical and social environments of communities. It is also about developing and advocating for policies that support health.

Module 9: Program Planning: Focus on Behavior Change
INDIVIDUAL AND INTERPERSONAL LEVEL BEHAVIOR CHANGE
On the individual and interpersonal level behavior change theories are categorized as “Cognitive-Behavioral” and focus on three key concepts:
● Knowledge affects action
● Knowledge is necessary but not sufficient to produce behavior change
● Perceptions, motivations, skills and the social environment are critical factors that influences behavior
This topic will highlight three behavior change models:
1. Health Belief Model (HBM)
2. Stages of Change (Transtheoretical) Model
3. Social Cognitive Theory
There are many others that may assist you in program planning; and several additional models are discussed in the Theory at a Glance assigned reading.
Health Belief Model
The Health Belief Model focuses on an individual’s perceptions of the threat of a health problem and the behavior change necessary to prevent or manage the problem. It was developed by Godfrey Hochbaum, Stephen Kegels, and Irwin Rosenstock in the 1950s and is regarded as the beginning of systematic theory-based research in health behavior. It remains one of the most recognized models in the field.
It includes six factors that influence decisions and an individual’s readiness to act:
● Perceived susceptibility
● Perceived severity
● Perceived benefits
● Perceived barriers
● Cues to action
● Self-efficacy

Because the Health Belief Model focuses on the of the threat of susceptibility, it is important to recognize that it is not appropriate for developing programs for all age groups. This is particularly the case when designing programs for adolescents, who often perceive themselves as invulnerable. It is very effective with many other populations when trying to reduce the threat of disease.
The following image is an example of a health promotion program focusing on the “threat of susceptibility”.

Stages of Change (Transtheoretical) Model
The Stages of Change (Transtheoretical) Model is based on the premise that behavior change is a process, not an event. As individuals attempt to change behavior, they move through five stages:
1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

Individuals can cycle back and forward in the process. The Stages of Change (Transtheoretical) Model It was developed by John Prochaska and Carlo DiClemente in 1983, and used to explain experiences of smokers trying to quit.
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This model has been used successfully in a variety of settings, and continues to be used to understand and examine health behaviors such as smoking, substance abuse, exercise and dietary behaviors. Dr. DiClemente is on the faculty of UMBC and leads its HABITS Laboratory.

Social Cognitive Theory (SCT)
Social Cognitive Theory focuses on the dynamic interrelationships of personal factors, environmental factors and human behavior. It was developed by Albert Bandura in 1986, and identifies three main factors that influence health behavior:
● Self-efficacy–Individual’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives
● Goals
● Outcome expectancies
Social Cognitive Theory’s critical element is self-efficacy. Factors effecting self-efficacy include:
● Affective Processes: Processes regulating emotional states and elicitation of emotional reactions
● Cognitive Processes: Thinking processes involved in the acquisition, organization and use of information
● Motivation: Activation to action–level of motivation is reflected in choice of courses of action, and in the intensity and persistence of effort
● Self-Regulation: Exercise of influence over one’s own motivation, thought processes, emotional states and patterns of behavior

Bandura supported the view that individual actions are the result of an interaction among personal, behavioral and environmental influences. Individuals consider the results of their own behavior, personal factors, and alter their environment to change subsequent behavior. Bandura changed the label of his theory from social learning to social “cognitive theory” to emphasize the role that cognition plays in “people’s capability to construct reality, self-regulate, encode information, and perform behaviors” (para 2).
Source: Pajares, F. (2002).Overview of social cognitive theory and of self-efficacy. Retrieved from http://www.uky.edu/~eushe2/Pajares/eff.html

Social Cognitive Theory has been used successfully in changing behavior in a number of domains including dietary behavior, HIV/AIDs, breastfeeding and pain control. One of the most well recognized is the Stanford Chronic Disease Self-Management Program developed by Kate Lorig, DrPH, RN.
For more information on the application of behavior models in community health promotion programs read Kreuter, M., Lezin, N.,Kreuter, M., Green, L. Community health promotion Ideas that work Chapter 5: Theory applied, Sudbury, MA: Jones and Bartlett. Available through HS/HSL Course Reserves in 780 blackboard.
COMMUNITY-LEVEL BEHAVIOR CHANGE
Community-level models provide frameworks for multi-dimensional approaches to health promotion. They augment educational efforts by incorporating strategies to change the social and physical environment to encourage behavior change. Community-level models are the key to public health approaches to preventing and controlling disease. They utilize an ecological approach to explore how social systems function and change and how community members and organizations can mobilize to support positive behavior change. Community-level models provide evidence-based strategies for a variety of settings including health care organizations, schools, worksites, community groups and government agencies.
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Frameworks for Intervening on the Community-Level
1. Community Organization/Participatory Models
2. These models help community groups to identify common problems, mobilize resources and develop and implement strategies to reach collective goals. The models generally involve community development, social planning and social action to increase the community’s capacity to solve problems. They utilize a variety of techniques to achieve change noted in the table below.

Advocacy is an important tool in community organization and effective program planning. Health policies, within organizations and on the local, state and national level, that support programs have the capacity to greatly increase the impact of programs.Diffusion of Innovation
3. The Diffusion of Innovation model explains how a new idea or product gains momentum and spreads through a given population. Diffusion increases the population reached by community-based interventions and strengthens the public health impact of initiatives.
Characteristics of innovations that influence the extent to which a recommendation will be adopted:
○ Relative advantage
○ Compatibility
○ Complexity
○ Trialability
○ Observability
4. The process of adoption is similar to a bell-shaped curve with five categories of adopters:
○ Innovators
○ Early adopters
○ Early majority adopters
○ Late majority adopters
○ Laggards
5. Identifying the characteristics of populations in each adopter category is critical to effective program planning to meet the specific needs of a community. Many of the adoption strategies used in business have been utilized to promote public health programs. Check out the local Brick Bodies website to see how they successfully address the characteristics of innovations and think how you can use some of these strategies in program planning.

Source: http://image.slidesharecdn.com/rogersdiffusionofinnovationsmodel-120205231217-phpapp01/95/rogers-diffusion-of-innovations-model-4-728.jpg?cb=1328483651
For more information on the Diffusion of Innovation Model please review the following website: http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories4.htmlCommunication Theories
6. Communication Theories describes how different types of messages affect health behavior. They considers how messages are developed, relayed, received and acted upon. Public health communications involve the scientific development, strategic dissemination and evaluation of relevant, accurate, accessible and understandable health information, communicated to and from intended audiences to advance the public’s health.
Public health communications utilize multiple approaches:
○ Tailored messages at the individual level
○ Targeted messages at the group level
○ Social marketing at the community level
○ Media advocacy at the policy level
○ Mass media campaigns at the population level
Health communications alone have generally not been shown to sustain behavior change. (Think of the many times that health professionals provide brochures or tip sheets or just comment on needed behavior change, such as weight loss, and do not find their patients complying.) Health communications need to be coupled with other strategies that change the social and physical environment. Recall the discussion of the North Karalia/Finland experience.
The Centers for Disease Control and Prevention is a leader in health communications and health literacy. It offers a wide variety of tools available at varying level to support public health programs. Its audience insight series offers tools to enhance health communication with target populations including specific ethnic groups, providers, teenagers and baby boomers. Its Gateway to Health Communications and Social Marketing Practice provides tools and templates to develop health communication and social marketing campaigns and programs.
Guide to Community Preventive Services
The Community Preventive Services Task Force was established in 1996 by the U.S. Department of Health and Human Services to identify population health interventions that are scientifically proven to save lives, increase lifespans, and improve quality of life. The task force produces recommendations and identifies evidence gaps to help inform the decision making of federal, state, and local health departments, other government agencies, communities, healthcare providers, employers, schools and research organizations.
Similar to its companion document, the Guide to Clinical Preventive Services, the Guide to Community Preventive Services is regularly updated to assist program planners study and replicate evidence-based programs and policies to improve health and prevent disease.
Systematic reviews are used to answer these questions:
● Which program and policy interventions have been proven effective?
● Are there effective interventions that are right for my community?
● What might effective interventions cost; what is the likely return on investment?
Explore the website and use this important reference as you begin to develop your programs.
Module 10: Leading Causes of Morbidity and Mortality
OVERVIEW
This module begins the final section of the course focusing on population-based health promotion and community practice. The purpose of this module is to further examine two of the leading causes of mortality and morbidity—cancer and mental health disorders. It emphasizes disease prevalence and prevention strategies and population-based initiatives on the national and state level designed to reduce the burden of cancer and mental health disorders.
Objectives
At the conclusion of this module, the learner will be able to:
● Explain the prevalence of cancer in relation to the leading causes of mortality and morbidity
● Explain the prevalence of mental health disorders in relation to the leading causes of morbidity
● Identify prevention strategies for cancer
● Identify prevention strategies for mental health disorders
● Discuss national planning models for cancer
● Discuss national planning models for mental health disorders
● Review the state goals for addressing population-based cancer control
● Review the state goals for addressing population-based mental health disorders
Required Readings
● American Cancer Society. (2021). Facts and Figures 2021, pp. 1-10, 30-44, 45-49. Available at https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2021.htm
● Centers for Disease Control and Prevention. (November 18, 2016). Potentially Preventable Deaths from the Five Leading Causes of Death —United States, 2010 and 2014, Morbidity and Mortality Week Report, 63(17). Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6545a1.htm
● National Alliance on Mental Illness. (2021). Mental Health By The Numbers. Available at http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
● Risk and Protective Factors:
https://youth.gov/youth-topics/youth-mental-health/risk-and-protective-factors-youth
● Substance Abuse and Mental Health Services Administration. (2021). Mental and Substance Use Disorders. Available at http://www.samhsa.gov/disorders
Recommended
● National Cancer Institute. (2020). Cancer trends progress report: 2020 update. Available at http://www.progressreport.cancer.gov/
● World Health Organization. (2021). Mental Health Action Plan 2013-2030 pp 1-10.
Directions
Read the module content and activities. Then complete the assignment for the module.
Module 10: Leading Causes of Morbidity and Mortality
RANKINGS
Mortality
Recall that many of the the leading causes of death in the U.S. are heavily influenced by lifestyle risk factors.
Age-adjusted Death Rates for the 10 Leading Causes of Death in the US, 2019 and 2020

Source: NCHS Data Brief No. 427, December 2021
The CDC reported that compared to 2010, 87,950 deaths from diseases of the heart (decrease of 4%), 63,209 from cancer (decrease of 25%), 29,132 from chronic respiratory diseases (increase of 1%), 15,175 from cerebrovascular diseases (decrease of 11%), and 45,331 from unintentional injuries (increase of 23%) could potentially be prevented each year.

Source: CDC MMWR November 18, 2016 (most recent data available)

For more information on potentially preventable leading causes of death in the U.S., review the required reading available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6545a1.htm
Morbidity

On the international level the World Health Organization identifies the leading causes of disability, measured by disability-adjusted life years (DALYs), noting that back pain and musculoskeletal disorders and major depressive and anxiety disorders have the greatest influence on morbidity.

CANCER — MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Cancer is the second leading cause of death in the United States. In 2021, 1.9 million new cases of cancer will be detected, about 608,570 people are expected to die from cancer, almost 1670 per day. The National Cancer Institute reports that direct medical costs for cancer hospitalization and outpatient services on an annual basis is $183 billion. This does not include the cost due to lost productivity from morbidity and premature mortality. Men have nearly a 1 in 2 chance of developing cancer and women have a 1 in 3 chance of developing cancer. Cancer is caused by both external factors such as tobacco, infectious organisms, radiation and chemical exposure and internal factors such as inherited mutations, hormones, immune conditions and metabolic mutations.

Source: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf
How Information on Cancer Across the Nation Is Obtained
Medical facilities such as hospitals, doctor’s offices, and pathology laboratories send information about cancer cases to their cancer registry. Most information comes from hospitals, where highly trained cancer registrars transfer the information from the patient’s medical record to the registry’s computer software using standardized codes. The data on diagnosis, follow-up, treatment and survival are then sent to a central cancer registry, a population-based resource for examining cancer patterns. The first central cancer registry was established in Connecticut in 1935. Many states developed similar programs soon afterwards. However, it was not until the National Program of Cancer Registries (NPCR) was established by Congress through the Cancer Registries Amendment Act in 1992 that all states began collecting data on cancer occurrence (type, extent, and location) and the type of initial treatment. The NPCR is administered by CDC.
Together, CDC’s NPCR and the National Cancer Institute’s (NCI’s) Surveillance, Epidemiology and End Results (SEER) Program collect incidence data for the entire U.S. population. CDC’s National Center for Health Statistics’ National Vital Statistics System collects mortality data. This national coverage enables researchers, clinicians, policy makers, public health professionals, and members of the public to monitor the burden of cancer, evaluate the success of programs, and identify additional needs for cancer prevention and control efforts at national, state, and local levels.
Cancer registry data are used to:
● Monitor cancer trends over time
● Show cancer patterns in various populations and identify high-risk groups
● Guide planning and evaluation of cancer control programs
● Help set priorities for allocating health resources
● Advance clinical, epidemiologic and health services research.
Prevention
According to the National Cancer Institute, 80% of cancers are due to factors that have been identified and can potentially be controlled. Not only can we potentially prevent most cancers, we can also improve the survival rates of those people who have cancer.

A substantial proportion of cancers can be prevented through risk reduction strategies:
● Avoid Tobacco
○ Cigarette smoking
○ Cigar smoking
○ Smokeless tobacco
○ Secondhand smoke
Click here for more information on tobacco and review pages 39-44.
Healthy Nutrition and Physical Activity
● Maintain a healthy weight
● Consume a healthy diet with emphasis on plant food
● Limit alcohol
● Adopt a physically active lifestyle
Click here for more information and review pages 45-49.
Minimize Exposure to Environmental Cancer Risk
● Ultraviolet light
● Infectious agents including HPV, Hepatitis B and C and HIV
● Medical treatments
● Carcinogens that exist as pollutants
● Naturally occurring and occupational carcinogens
Click here to review NCI’s Cancer Prevention Overview Description of the Evidence
The number of new cancer cases can be reduced through minimizing risk exposure; many cancer deaths can be prevented through early detection. Screening is becoming more accessible for many cancers, and together with health education and referral services, plays a key role in reduce cancer incidence and deaths. The Affordable Care Act eliminates deductibles for many types of screening and CDC offers free or low-cost mammograms and Pap tests nationwide and free or low-cost colorectal cancer screening – through 24 state health departments, six universities and one American Indian tribe.

POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF CANCER
National
Since 1998, the CDC has been supporting partnerships across the U.S. to assess the burden of cancer, determine priorities, and develop and implement cancer plans under the National Comprehensive Cancer Control Program (NCCCP). Comprehensive control programs focus on promoting healthy lifestyles and recommended cancer screenings, educate communities about cancer symptoms, increase access to quality cancer care, and enhance survivors’ quality of life.

The CDC has developed a tool kit for planning and promoting cancer prevention initiatives for the community. Explore this resource to learn more about:
● Understanding a community’s needs
● Planning a community outreach strategy
● Building community partnerships
● Evaluating efforts
● Resources available

Maryland’s overall cancer mortality rate ranks 31th in the nation. Over 31,000 new cases of invasive cancer are diagnosed each year and nearly 11,000 Marylanders die from cancer each year. The most commonly diagnosed cancers are breast, pancreas, lung and bronchus and colon and rectum cancers. Lung cancer is the leading cause of cancer mortality followed by colorectal, breast, pancreatic and prostate. Maryland’s Comprehensive Cancer Control Plan serves as a guide for planning, directing and implementing, evaluating or conducting cancer control research. It identifies 3 goals and objectives to:
1. Increase cancer prevention behaviors in priority areas
○ Tobacco use and exposure
○ Healthy weight, nutrition and physical activity
○ Alcohol consumption
○ Cancer vaccines
○ Ultraviolet radiation exposure
○ Radon exposure
○ Environmental and occupational exposures
2. Reduce the burden of cancer
○ Reach new targets for age-adjusted incidence for high burden cancers
○ Reach new targets for age-adjusted mortality for high burden cancers
○ Achieve screening targets for high burden cancers
○ Reduce disparities in cancer incidence and mortality to achieve new targets
3. Increase quality of life for cancer survivors
○ Reduce days when poor physical or mental health prevent usual activities
○ Improve pain management
○ Increase written summaries increase by providers of treatments received and check-ups after completing treatment
○ Obtain data on survivors who have completed advanced directives and advance care planning
○ Access to palliative care services by maintaining Maryland’s “A’ grade on the Center to Advance Palliative Report Card
○ Expand data collection of data on hospice utilization
○ Improve surveillance of sexual and gender minority populations including health risks
For more information, review the 2021-2025 Cancer Control Plan available at http://phpa.dhmh.maryland.gov/cancer/cancerplan/Documents/
MD%20Cancer%20Program_508C%20with%20cover.pdf
N.B. The plan is also an excellent example for developing goals and objectives and strategies that can be useful for part 2 of your paper.
MENTAL HEALTH AND MENTAL DISORDERS—MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
The burden of mental illness in the U.S. is among the highest of all diseases and mental disorders are among the most common causes of disability. The National Institute of Mental Health reported an estimated 51.5 million adults aged 18 and older, or approximately 20% of the population, with any mental illness (AMI) defined as a mental, behavioral or emotional disorder (excluding developmental and substance use disorders) diagnosed within the past year. An estimated 5.2%, or 13.2 million, of these adults are diagnosed with serious mental disability (SMI) resulting in significant functional impairment which substantially interferes with or limits one or more major life activities. Serious mental illness is associated with an estimated total economic cost of $317 billion per year. An additional 18.7 million or approximately 8% of the adult population have a substance use disorder and 10.2 million of these adults have both a mental disorder and a substance use disorder, defined as co-occurring disorders.
Sources:
https://www.nami.org/NAMI/media/NAMI-Media/Infographics/NAMI-You-Are-Not-Alone-FINAL.pdf
https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

Additional source: https://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf

Mental disorders are common among children in the U.S. as well. Approximately 20% of children experience a seriously debilitating mental disorder. The following graphs show the lifetime prevalence of a mental health disorder for 13 to 18 year olds. It also shows that prevalence is equal for both genders, but does differ between various age groups for adolescents.

Mental health disorders are associated with the prevalence, progression and outcome of many of the leading causes of death. Mental illnesses, such as depression and anxiety, affect the ability to participate in health-promoting behaviors. Physical health problems can have a serious impact on mental health and influence the ability to participate in treatment and recovery. Individuals with untreated mental health disorders are at high risk for unhealthy and unsafe behaviors, including alcohol or drug abuse, violent or self-destructive behavior, and suicide. Adults with serious mental illness die on average 25 years earlier.
Treatment
Treatment for mental illness and substance use disorders is far from ideal. Approximately 60% of adults and 50% of children with mental illness received no mental health services in the previous year.
Source: http://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf

SAMHSA’s Behavioral Health Barometer provides an overview of the issues for the state of Maryland and the U. S. as a whole.

Prevention
Many mental health disorders can be treated effectively and prevention of mental health disorders is a growing area of research and practice. Early diagnosis and treatment can decrease the disease burden of mental health disorders as well as associated chronic diseases.
The existing model for understanding mental health and mental disorders emphasizes the interaction of social, environmental, and genetic factors throughout the lifespan. It focuses on risk factors which predispose individuals to mental illness and protective factors which reduce the risk of developing mental disorders at four levels: self, family, community and society.

Individual-level risk factors include genetic predisposition to addiction or exposure to alcohol prenatally, academic failure and scholastic demoralization, attention deficits, caring for chronically ill or dementia patients, child abuse and neglect, chronic insomnia, chronic pain, early pregnancies, elder abuse, emotional immaturity and dyscontrol, substance abuse, loneliness; poor work skills and habits, reading, sensory or functional disabilities, social incompetence and stressful life events
Individual-level protective factors can include positive self-image, self-control, social competence, ability to face adversity, autonomy, exercise, feelings of security, mastery and control, literacy, problem solving skills, self-esteem, conflict management skills, resiliency, socioemotional growth and stress management
Family-level risk factors include parents who use drugs and alcohol or who suffer from mental illness, child abuse and maltreatment and inadequate supervision, family conflict or disorganization
Family-level protective factors would be parental involvement, positive attachment and early bonding, social support of family and friends
Community-level risk factors include access to drugs and alcohol, displacement, isolation and alienation, lack of education, transport, housing; neighborhood disorganization, peer rejection, poverty, violence, poor nutrition, work stress and unemployment
Community-level protective factors might include the availability of faith-based resources and after-school activities, empowerment, positive interpersonal interactions, social support and community networks
Society-level risk factors can include norms and laws favorable to substance use, racial injustice and discrimination, social disadvantage, lack of economic opportunity and war
Society-level protective factors include policies limiting availability of substances or anti-hate laws, defending marginalized populations, social participation, social services, social responsibility and tolerance
In addition to advancements in the prevention of mental disorders, there continues to be steady progress in treating mental disorders as new drugs and stronger evidence-based outcomes become available.

POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF MENTAL HEALTH AND MENTAL DISORDERS
National Planning Models
SAMHSA’s Strategic Prevention Framework (SPF) is a five step guide to the selection, implementation and evaluation of evidence-based, culturally appropriate, sustainable community-based behavioral health promotion and substance use prevention programs
The SPF includes these five steps:
● Step 1. Assess Needs
● Step 2. Build Capacity
● Step 3. Plan
● Step 4. Implement
● Step 5. Evaluation

SAMHSA’s Focus on Prevention is a national planning model for communities to move from concerns about substance abuse to evidence-based solutions. A unique feature of this guide is that it recognizes the different problems faced and the varying resources and experiences to develop prevention programs.
SAMHSA’s Screening, Brief Intervention and Referral to Treatment (SBIRT) is a public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at risk for developing those disorders that focuses on the many different types of community settings that provide opportunities for early intervention with at-risk substance users before more severe consequences occur.
Alcohol and drug abuse occur along a continuum in terms of level of consumption and consequences as is noted in the treatment pyramid noted below. The pyramid has been developed to show the role of SBIRT in addressing needs across the continuum of use. SBIRT has three major components: screening, brief intervention and referral to treatment.

Statewide

Source: Source: https://bha.health.maryland.gov/Documents/Final%202020-2021%20Behavioral%20Health%20Plan.pdf
The Maryland Department of Health’s Behavioral Health Administration Behavioral Health Strategic Plan is a blueprint for planning, policy and services that aims to provide a coordinated system of care to residents with behavioral health conditions. Through publicly funded services and supports, the Behavioral Administration works to promote recovery, resiliency, health, and wellness for individuals who are at risk for emotional, substance-related, addictive, and psychiatric disorders to improve their ability to function effectively in their communities.
DHMH’s planning goals align with SAMSHA’s strategic initiatives and target mental illness, substance-related and other addictive disorders. The goals are to:
● Increase access to care
● Improve quality of care in the public behavioral health system
● Improve coordination of care
● Strengthen and expand suicide prevention programs
For more information review the Behavioral Health Plan available at https://health.maryland.gov/bha/Documents/Final%202020-2021%20Behavioral%20Health%20Plan.pdf
Module 11: Infectious Diseases
OVERVIEW
Despite tremendous advances in infectious disease prevention efforts, vaccinations, antibiotics and other treatments that have resulted in increased longevity, millions of Americans still contract infectious diseases each year. Worldwide, infectious diseases are the leading cause of death of people under the age of 60. Right now, we are in the midst of the COVID-19 pandemic. All of us are learning how to address it and many are on the frontlines treating patients and trying to control the spread of the disease. (Information on COVID-19 will be addressed in Module 13 Critical Issues in Population Health).
The purpose of this module is to provide an overview of infectious disease transmission and interventions to control the chain of infection. It emphasizes infectious disease prevalence and prevention strategies and population-based initiatives on the national and state level designed to reduce the burden of infectious diseases in general and HIV/AIDS specifically.
Objectives
At the conclusion of this module, the learner will be able to:
● Explain the modes of transmission of infectious diseases
● Identify prevention strategies for infectious diseases
● Identify prevention strategies for HIV/AIDS
● Discuss national planning models for infectious diseases
● Discuss national planning models for HIV/AIDS
● Review the state goals for addressing population-based infectious diseases prevention
● Review the state goals for addressing population-based HIV/AIDS prevention
● Describe a model community-based HIV/AIDS prevention program
Required Readings
● Centers for Disease Control and Prevention. (2011). A CDC Framework for Preventing Infectious Diseases (2011).Overview Available at https://www.cdc.gov/ddid/docs/ID-Framework-2pageoverview.pdf
● Trust for America’s Health and Robert Wood Johnson Foundation (2015). Outbreaks: Protecting Americans from Infectious Diseases 2015. Introduction (pp. 4-10); Reducing Sexually Transmitted Infections and TB (pp. 81-92). Available at https://www.issuelab.org/resources/23703/23703.pdf
● AIDS.gov. (2021). HIV/AIDS Care Continuum. Available at http://aids.gov/federal-resources/policies/care-continuum/
Recommended Readings
● Trust for America’s Health and Robert Wood Johnson Foundation (2015). Outbreaks: Protecting Americans from Infectious Diseases 2015. Available at https://www.issuelab.org/resources/23703/23703.pdf
● National HIV/AIDS Strategy for the United States: Updated to 2020. (n.d.) Available at https://www.hiv.gov/sites/default/files/nhas-update.pdf AIDS.gov. (n.d.). HIV/AIDS Basics. Available at http://aids.gov/hiv-aids-basics/
● CDC Coronavirus COVID-19 Available at https://www.cdc.gov/coronavirus/2019-ncov/index.html
Directions
Read the module content and activities. There will be no discussion board this week. Please continue working on part two of your paper.
TRANSMISSION
Infectious diseases arise from the complex interactions between the agent, host and environment.

Transmission occurs when the agent leaves its reservoir or host through a portal of exit, is conveyed by some mode of transmission, and enters through an appropriate portal of entry to infect a susceptible host. This sequence is referred to as the chain of infection.

Agent/Pathogen—virus, bacterium or parasite that causes the disease in humans
Reservoir—place where the agent lives and multiplies in the environment or another human or animal species
Portal of Exit/Mode of Transmission—how the agent travels from one host to another (aerosols, sexual contact, body fluids, blood-borne) or from a reservoir to a new host (inanimate objects or vectors e.g. insects, food, water
Portal of Entry—how the agent enters a new host (aerosols, fecal-oral, skin, mucous membranes, blood)
Susceptible host— depends on genetic or constitutional factors, specific immunity or non-specific factors that protect against infection, e.g., skin, mucous membranes, gastric acidity, respiratory cilia or nonspecific immune response, and factors that increase susceptibility to infection, e.g., malnutrition, alcoholism or disease or therapy that impairs the nonspecific immune response
Understanding the portals of exit and entry and modes of transmission serves as the basis for determining control measures which are often directed toward the segment in the chain of infection that is most susceptible to intervention and include:
● Controlling or eliminating agents at their source of transmission
● Protecting portals of entry
● Increasing host resistance
Major Infectious Disease Threats
Many factors contribute to the growth and spread of infectious diseases:
● Global travel
● Urbanization
● Immigration
● Housing
● Health care practices
● Public health infrastructure
● Food production and preparation
● use and misuse of antibiotics
● microbial adaptation
● human behavior
These factors, compounded by the ability of micro-organisms to evolve and adapt to changing populations, environments, practices and technologies, create ongoing threats to health and continually challenge efforts to prevent and control infectious diseases.
Case Study: Herd Immunity and the Increase in Measles Cases
Herd Immunity—Describes how a population is protected from a disease after vaccination by stopping the infectious agent from being transmitted between people. Sufficiently high levels of herd immunity can indirectly protect individuals who cannot be vaccinated.
The level of herd immunity needed to protect the population varies by the contagion level of the disease. Measles is highly contagious and to achieve herd immunity requires at least 90-95% of the population to be vaccinated. Polio is less contagious and to achieve herd immunity requires 80-85% of the population to be vaccinated.
On average, approximately 92.7% of children in the US are vaccinated against measles but rates vary considerably by state and communities within states.

https://www.cdc.gov/measles/cases-outbreaks.html (March 8, 2021)
CDC reports that misinformation about the safety of the measles/mumps/rubella (MMR) vaccine is significant factor contributing to the outbreak of measles and that organizations are deliberately targeting communities with inaccurate and misleading information about vaccines. CDC recommends that parents discuss vaccination with their children’s health care providers and encourages health professionals and local leaders to provide accurate and scientific information to counter misinformation. For more information click on https://www.cdc.gov/media/releases/2019/s0424-highest-measles-cases-since-elimination.html.
FIGURE 2. Potentially achievable coverage*,†,§ with measles, mumps, and rubella vaccine (MMR) among kindergartners — 49 states, 2018–2019 school year

* Potentially achievable coverage is estimated as the sum of the percentage of students with up-to-date MMR and the percentage of students without up-to-date MMR and without a vaccine exemption.

Source: https://www.cdc.gov/mmwr/volumes/68/wr/mm6841e1.htm#F1_down (October 17, 2019)
The most common reasons given to US health care professionals by families who refuse to vaccinate their children are as follows:

Source: https://www.statista.com/statistics/665592/reasons-families-refused-vaccinations-health-care-professionals-us/
The WHO identifies vaccine hesitancy as one of the ten leading threats to global health stating the complacency, inconvenience in access, and a lack of confidence in the vaccine are key factors that have led to a resurgence of diseases such as measles in countries that were close to eliminating them. For more information click on https://www.statista.com/topics/5166/vaccine-hesitancy-in-the-us/.
POPULATION-BASED INITIATIVES TO REDUCE INFECTIOUS DISEASES
National Programs

The Trust for America’s Health in its compelling report entitled Outbreaks: Protecting Americans from Infectious Diseases 2015 emphasizes that fighting infectious disease requires constant vigilance and tools to control ongoing outbreaks, detect new and reemerging outbreaks and monitor for potential bioterrorist threats. The report highlights the following major infectious threats:
● Superbugs
● Middle East Respiratory Syndrome
● Foodborne Illnesses
● HIV/AIDS and Viral Hepatitis
● Healthcare-associated Infections
● Influenza (The Flu)
● Global Public Health Capacity
For more information, review the required reading (pp. 4-10) available at https://www.issuelab.org/resources/23703/23703.pdf
The report ranks the states on the ten following indicators with zero being the lowest possible score and ten the highest:
1. Public Health Funding
2. Flu Vaccination Rates
3. Childhood Immunization School Requirement Policies
4. HIV/AIDS Surveillance
5. Syringe Exchange Programs
6. Climate Change and Infectious Disease
7. Central Line-associated Bloodstream Infections
8. Public Health Laboratories with Biosafety Professionals
9. Public Health Laboratories that Provide Biosafety Training
10. Food Safety
Scores ranged from 8 (best) in Delaware, Kentucky, Maine, New York and Virginia to – 3 (worst) in Idaho, Kansas, Michigan, Ohio, Oklahoma, Oregon and Utah.

Source:http://healthyamericans.org/assets/files/TFAH-2015-OutbreaksRpt-FINAL.pdf

The CDC Framework for Preventing Infectious Diseases is the U.S. guide for improving the country’s ability to prevent known infectious diseases and to recognize and control rare, highly dangerous and emerging infectious diseases.
The framework targets three essential elements:
1. Strengthen public health fundamentals including infectious disease surveillance, laboratory detection and epidemiological investigation
2. Identify and implement high-impact public health interventions to reduce infectious disease.
3. Develop and advance policies to prevent, detect and control infectious diseases
The framework highlights nine diseases:

For more information, review the required reading available at https://www.cdc.gov/ddid/docs/ID-Framework-2pageoverview.pdf
Click here for more information on the CDC Framework for Preventing Infectious Diseases
National Notifiable Disease Surveillance System (NNDSS)
The CDC maintains the National Notifiable Disease Surveillance System, based on voluntary reporting of infectious and non-infectious diseases and outbreaks from 57 states and territories. The NNDSS facilitates the sharing of health information to monitor, control and prevent the occurrence and spread of state-reportable and nationally notifiable diseases and conditions. It is also used to improve and standardize public health surveillance systems for state and local health departments as well as with health information technology systems used by hospitals, laboratories and private providers.
Statewide Programs
The Maryland Department of Health’s infectious disease efforts are housed within the Prevention and Health Promotion Administration.
The Maryland Department of Health’s Infectious Disease Bureau includes specific centers that focus on the following:
● Vaccine-Preventable Diseases
● Zoonotic and Vector-borne Diseases
● Adult Viral Hepatitis Prevention
● Sexually Transmitted Infections Prevention
● Human Immunodeficiency Virus Prevention
● Human Immunodeficiency Virus Care Services
● Tuberculosis Control
Reportable Diseases
The Maryland Department of Health also maintains the registry of diseases, conditions, outbreaks and unusual manifestations that are reportable under the Code of Maryland Regulations (COMAR) 10.06.01.03 C. These regulations stipulate what conditions should be reported, who should report, primarily health care providers and laboratories, how reporting should occur, where reports are sent, important time lines and when laboratories should submit specimens to the state public health laboratory.
Reporting cases of known or suspected infectious diseases protects the public’s health by ensuring the proper identification and follow-up of cases. Public health workers at both local and state levels follow individual cases to ensure proper treatment, identify potential sources of infection, provide education to reduce the risk of transmission, identify susceptible contacts and take other measures aimed at reducing the spread of disease. Analysis of data across all cases helps to monitor the impact of those conditions, measure trends, identify areas of risk, detect outbreaks, monitor control efforts and allocate resources effectively.
Take a few minutes to review information on reportable diseases in Maryland at https://phpa.health.maryland.gov/Pages/reportable-diseases.aspx.
Click here for more information on Maryland Department of Health’s Infectious Disease Bureau.
HIV/AIDS PREVALENCE AND PREVENTION
The CDC estimates that 1.1 million people are living with HIV infection in the U.S., 14% of whom (1 in 7) are unaware of their infection. During the last ten years, the number of people living with HIV has increased, while the annual number of new HIV infections has declined by 19% from 2005 to 2014 and has leveled off to approximately 39,000 new cases per year. In the U.S., HIV is spread mainly by having sex or by sharing injection drug-use equipment with an infected person.
As noted in the graph below, gay, bisexual and other men who have sex with men (MSM) are most seriously affected by HIV.

Source: https://www.cdc.gov/hiv/pdf/group/age/youth/cdc-hiv-youth.pdf

U.S. Geographic Distribution
Significant variations in the HIV and AIDS epidemic exist across the country. It is primarily concentrated in urban areas and higher rates were reported in the South.

Source: https://www.cdc.gov/hiv/statistics/overview/ataglance.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhiv%2Fstatistics%2Fbasics%2Fataglance.html
Prevention
HIV is transmitted through blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids and breast milk from an infected person. These fluids must come into contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream for transmission to occur. Click here for more information on HIV transmission.
HIV can be prevented by avoiding exposure to the fluids that can transmit the virus through using condoms correctly and consistently, limiting the number of sexual partners, never sharing needles and through biomedical options such as pre-exposure and post-exposure prophylaxis. Click here for more information on HIV prevention.
Prevention efforts are challenged by the facts that of the 1.1 million Americans living with HIV:
1. approximately 14% are unaware of their serostatus and
2. only 56% are virally suppressed.

Source: https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum
To better understand the disparities in HIV prevention at all levels click on this video and review the required reading at http://aids.gov/federal-resources/policies/care-continuum/
Inroads have been made in advancing early treatment and routine testing for HIV. For more information review the CDC website for HIV testing available at https://www.cdc.gov/hiv/testing/.
Health care workers follow Universal Precautions for Preventing Transmission of Bloodborne Infections to prevent infection from HIV/AIDs. Click here for more information.
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF HIV/AIDS
National

Source: https://www.hiv.gov/federal-response/hiv-national-strategic-plan/hiv-plan-2021-2025
The HIV National Strategic Plan is the country’s comprehensive coordinated HIV/AIDs roadmap for ending the HIV epidemic in the US and reducing the number of new infections by 90% by 2030. It is the nation’s third consecutive five-year plan and was developed based on public input and ideas from individuals living with HIV as well as other stakeholders and interested parties
The HIV Plan focuses on four goals and targeted strategies:
● Prevent new HIV infections
○ Increase awareness of HIV
○ Increase knowledge of HIV status
○ Expand and improve implementation of effective prevention interventions, including treatment as prevention, PrEP, PEP, and SSPs, and developing new options
○ Increase the capacity of health care delivery systems, public health, and the health workforce to prevent and diagnose HIV
● Improve HIV-related health outcomes of people with HIV
○ Link people to care immediately after diagnosis and provide low-barrier access to HIV treatment
○ Identify, engage, or reengage people with HIV who are not in care or not virally surpressed
○ Increase retention in care and adherence to HIV treatment to achieve and maintain long-term viral surpression
○ Increase the capacity of health care delivery systems, public health, and the health workforce to serve people with HIV

● Reduce HIV-related disparities and health inequities
○ Reduce HIV-related stigma and discrimination
○ Reduce disparities in new HIV infections, in knowledge of status, and along the health care continuum
○ Engage, employ, and provide public leadership opportunities at all levels for people with or at risk for HIV
○ Address social determinants of health and co-occurring conditions that exacerbate HIV-related disparities
● Achieve integrated and coordinated efforts that address the HIV epidemic among all partners and stakeholders
○ Integrate programs to address the syndemic of HIV, sexually transmitted infections (STIs), viral hepatitis, and substance use and mental health disorders
○ Increase coordination of HIV programs across all levels of government and with faith-based and community-based organizations, the private sector, academic partners, and the community
○ Enhance the quality, accessibility, sharing, and use of data, including HIV prevention and care continuum and social determinants of health data
○ Identify, evaluate, and scale up best practices including through translational, implementation, and communication science research
○ Improve mechanisms to measure, monitor, evaluate, report, and disseminate progress toward achieving organizational, local, and national goals
For additional information, review the National HIV Strategic Plan at https://hivgov-prod-v3.s3.amazonaws.com/s3fs-public/HIV-National-Strategic-Plan-2021-2025.pdf
●
Statewide
The Maryland Department of Health Centers for HIV Prevention and Health Services focus on:
● reducing the transmission of HIV,
● helping the nearly 32,000 Marylanders living with HIV/AIDs live longer and healthier lives through the development, and
● implementation of comprehensive, compassionate and quality services for both prevention and care.
Its Integrative HIV Plan 2018-2022: A Comprehensive, Coordinated Response to HIV for Baltimore and Maryland is based on the National HIV Strategy and serves as Maryland’s roadmap for the development of a comprehensive system of HIV care in the state.
The plan includes four goals:
1. Reduce new infections
2. Increase access to care and improve health outcomes for people living with HIV
3. Reduce health disparities and inequities
4. Achieve a more coordinated response
The plan expands Maryland’s approach to the continuum of care to focus prevention efforts on vulnerable populations and awareness among the general population.

The expanded continuum is organized into five domains that serve as the framework for the plan and the activities to achieve the goals.

The Jacques Initiative: A Baltimore Exemplar Program
The JACQUES Initiative (JI) program of the University of Maryland Institute of Human Virology is a holistic care delivery model that provides long-term treatment success for urban populations infected with HIV. Its goal is to decrease the morbidity and mortality associated with HIV through care delivery and providing early intervention services through activities including testing, outreach and linkage to care. The JI focuses on providing a “safe place” for individuals living with HIV through delivered services and providing access to research for all through the Journey to Wellness. There are five steps in the journey—engage, prepare, treat, support and develop.

Watch these two videos PTF Testing and LTC Video and Living Proof on the impact of this model on patient care.
The JI’s Preparing the Future (PTF) model program incorporates health, psychosocial and legal resources that facilitate HIV testing and linkages to care more routine and normalized. A central component of PTF brings together graduate students into teams from the University’s dentistry, law, medicine, nursing, pharmacy, and social work schools to address the goals of National HIV/AIDS Strategy (NHAS), including identifying new infections of HIV and increasing access to care for people living with HIV. PTF has been identified by the White House Office of National AIDS Policy as a model for communities across the country.
Module 12: Environmental Health, Occupational Health, Unintended Injuries and Violence
ENVIRONMENTAL HEALTH ISSUES–MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Environmental health encompasses preventing and controlling disease, injury and disability related to the interactions between individuals and their environment. The WHO defines environment as it relates to health as “all the physical, chemical, and biological factors external to a person, and all the related behaviors.”
Approximately 10% of premature morbidity and mortality in the U.S. is attributed to environmental causes. On the international level, the WHO estimates that nearly 25% of the total disease burden and 25% of deaths can be attributed to environmental factors that include:
● Exposures to hazardous substances in the air, water, soil and food
● Natural and technological disasters
● Physical hazards
● Nutritional deficiencies
● The built environment
In 2010 the American Nurses Association recognized the critical need to understand environmental health issues and added an Environmental Health Standard to its Scope and Standards of Practice.
Prevention
The Precautionary Principle enunciated in the 1998 Wingspread Statement as “when an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some causes and effect relationships are not fully established scientifically,” is a fundamental tenant for all environmental health endeavors.
Population and community-based strategies that target reducing environmental health risks include:
● Decreasing air pollution
● Protecting and minimizing drinking water and recreational water from infectious or chemical agents
● Reducing exposure to toxic substances and hazardous waste
● Maintaining healthy homes and communities by reducing exposure to indoor air pollution, inadequate heating and sanitation, structural problems, electrical and fire hazards and lead-based paint hazards
● Building capacity to measure and respond to environmental health hazards
● Increasing access to adequate water and sanitation facilities (global priority)
Poor environmental quality has its greatest impact on people whose health status is already at risk. As a result, environmental health initiatives must also address the societal and environmental factors that increase the likelihood of exposure and disease.
For more information review the required reading:
● Healthy People 2030. (2020). Environmental health. Available at https://health.gov/healthypeople/objectives-and-data/browse-objectives/environmental-health
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF ENVIRONMENTAL HEALTH ISSUES
National
The CDC National Center for Environmental Health (NCEH) plans, directs, and coordinates a program to protect the population from environmental hazards. It places special emphasis on safeguarding the health of vulnerable populations–children, the elderly, and people with disabilities. NCHE’s initiatives include the following:
● National Asthma Control Program that works with state health departments and NGOs to help people with asthma control their disease and live healthier, more productive lives.
● Built Environment & Health Initiative / Healthy Community Design Initiative that helps states and communities integrate health considerations into transportation and community planning to improve public health
● Healthy Homes and Lead Poisoning Prevention Program that protects children from lead exposure.
● Climate and Health Program that works to prevent and adapt to the health effects of extreme weather and other climate related issues.
● Environmental Health Laboratory that improves the detection, diagnosis, treatment and prevention of diseases resulting from exposure to environmental chemicals and selected other diseases that require advanced laboratory measurement for diagnosis.
● Core Environmental Health Services Program that works with state, local, tribal, and territorial environmental health practitioners to ensure that food, drinking water, and wastewater systems are safe.
● Environmental Public Health Tracking Program that tracks and reports environmental hazards and health problems that may be related.
● Radiation Studies Program that identifies and studies harmful exposures and provides important health communication and education regarding exposures.
● Safe Water Program that focuses on reducing waterborne exposures and diseases.
For more information of the NCHE please review the website at: https://www.cdc.gov/nceh/
Statewide
The Maryland Department of Health’s Environmental Health Bureau focuses on:
● Surveillance of environmental, occupational and injury conditions and exposures
● Regulation and control of hazards in food, home environments and the community
● Response to new and emerging hazards and environmental threats such as global climate change
Click here for more information on environmental health in Maryland.

Alliance of Nurses for Healthy Environments: An international effort started by the University of Maryland School of Nursing

The Alliance of Nurses for Healthy Environments (ANHE) is an international network of nurses who are acting on the premise that the environment and health are inextricably connected. ANHE is working to integrate environmental health intro nursing education, green health care workplaces, incorporate environmental exposure questions into patient histories, provide anticipatory guidance to pregnant women and parents about environmental risks to children, implement research that addresses environmental health questions and advocate for environmental health in the workplace and governmental institutions.
Watch this video to get a sense of the work of ANHE.
The University of Maryland School of Nursing offers an on-line certificate in Environmental Health. For more information click here.
OCCUPATIONAL HEALTH ISSUES–MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
The National Institute for Occupational Safety and Health (NIOSH) is dedicated to the safety and health of the 155 million workers in the U.S. NIOSH focuses on research needed to prevent the societal cost of work-related fatalities, injuries and illnesses which are estimated at $250 billion in medical costs and productivity in addition to the huge toll on workers, their families, businesses, communities and the nation’s economy.
The Bureau of Labor Statistics reports that 4764 work-related injury deaths occurred in 2020. This averages to 100 deaths a week or more than 13 deaths a day. Construction fatalities rank number one with over 21% or one in five worker deaths. The leading causes of worker deaths in construction are falls followed by struck by an object, electrocution, caught-in/between, and are referred to as the “fatal four”.
The estimated annual burden of occupational disease mortality resulting from selected respiratory diseases, cancer, cardiovascular disease, chronic renal failure and hepatitis is 49,000, with a range of 26,000 to 72,000. When occupational disease and injury data are combined, an estimated 55,200 deaths occur annually for occupational disease or injury with a range of 32,000 to 78,200. Occupational deaths are estimated to be the 8th leading cause of death in the U.S.
Sources:
Bureau of Labor Statistics Total Fatal injuries in all sectors Available at http://data.bls.gov/timeseries/FWU00X00000080N00
National Institute for Occupational Safety and Health Factsheet (2015) Available at https://www.cdc.gov/niosh/docs/2013-140/pdfs/2013-140.pdf
Steenland, K., Burnett, C., Lalich, N., Ward, E, & Hurrell, J. (2003). Dying for work: The magnitude of US mortality from selected causes of death associated with occupation. American Journal of Industrial Medicine, 43(5), 461-82. Available at http://www.ncbi.nlm.nih.gov/pubmed/12704620
U.S. Department of Labor. (n.d.). Commonly use statistics. Available at https://www.osha.gov/oshstats/commonstats.html
Prevention
Workers spend a quarter of their lifetime and up to half of their waking lives at work or commuting. Therefore, the workplace provides a unique setting for public health action. DHHS identifies back injuries as the leading cause of workplace disability and recommends the following basics to reduce the risk of injury or illness:
● Lift things safely
● Arrange equipment to fit and prevent repetitive motion injuries
● Take short breaks and stretch muscles
● Eat a healthy diet and stay active
● Maintain a healthy weight
● Get enough sleep
● Take steps to manage stress
● Identify health resources in the workplace
Addressing occupational safety and health is challenged by several key factors:
● Increasing diversity of the workforce resulting in some workers having increased risks of work-related diseases and injuries, particularly: racial and ethnic minorities, recent immigrants, younger and older workers, workers with genetic susceptibilities and workers with disabilities
● Workplaces are rapidly evolving as jobs in the current economy continue to shift from manufacturing to services
● Changes in the way work is organized—longer hours, compressed work weeks, shift work, reduced job security, part-time and temporary work
● New chemicals, materials, processes and equipment are being developed at an accelerating pace which poses emerging risks to worker health
OSHA is actively involved in promoting injury and illness preventions programs for the workplace. Click here for general guidance.
POPULATION-BASED INITIATIVES TO REDUCE THE BURDEN OF OCCUPATIONAL HEALTH ISSUES
National

The National Occupational Research Agenda (NORA) is a partnership program to foster innovative research and improved workplace practices. Since 1996 NORA has served as the research agenda for NIOSH and the nation.
NORA Priorities are based on:
● Number of workers at risk for a particular injury or illness
● Seriousness of the hazard or issue
● Probability that new information and approaches will make a difference
NORA is comprised of ten sectors that include:
● Agriculture, Forestry and Fishing
● Construction
● Healthcare and Social Assistance
● Manufacturing
● Mining
● Oil and Gas Extraction
● Public Safety
● Services
● Transportation, Warehousing and Utilities
● Wholesale and Retail Trade
The Healthcare and Social Assistance program includes an estimated 21 million paid workers in ambulatory healthcare services, hospitals, nursing and residential care facilities, veterinary health care, and social assistance settings who face risks including infectious diseases, musculoskeletal disorders, workplace violence, exposure to hazardous drugs and other chemicals, shift-work and psycho-social stressors. The Healthcare and Social Assistance program works with partners in industry, labor, trade associations, professional organizations, and academia. The program targets:
1. Mitigating the effects of suboptimal work organization characteristics such as scheduling, workload, sleep quality and duration, on outcomes such as stress, anxiety, fatigue, depression, burnout, suicide, and chronic illnesses
2. Preventing injuries from lifting, falls, sharp instruments, and a variety of physical hazards including radiation and noise
3. Interrupting transmission of bloodborne and respiratory pathogens and drug-resistant organisms
4. Minimizing exposure to hazardous drugs and chemicals, allergens, and other substances associated with risk for cancer, adverse reproductive outcomes, dermal diseases, and work-related asthma
5. Reducing injuries associated with violent acts, especially among home care workers and workers in non-standard work arrangements
For additional information on the National Healthcare and Social Assistance Agenda, click on https://www.cdc.gov/nora/councils/hcsa/agenda.html.
To review the workplace violence prevention course designed specifically for nurses developed by a team of experts including the SON’s Jane Lipscomb, PhD, RN, FAAN, emeritus professor, Community/ Public Health, click here.
For information on priorities for other NORA sectors, click here.
Total Worker Health (TWH) Program

In 2011, NIOSH launched the Total Worker Health (TWH) Program which integrates occupational safety and health protection with health promotion to prevent worker injury and illness and to advance worker health and well-being. TWH involves the comprehensive development and implementation of organizational programs, policies and practices that minimize or eliminate workplace physical, biological and psychosocial hazards and risks, promote healthy behaviors and provide resources for maintaining and optimizing a safe, healthy and productive workforce on and off of the job.
TWH strategies and interventions include:
● Provision of mandated respiratory protection programs that simultaneously and comprehensively address and provide supports for tobacco cessation
● Ergonomic consultations that discuss work design, joint health and arthritis prevention and management strategies
● Provision of onsite, comprehensive workplace screenings for work and non-work related health risks
● Models that combine occupational health services with workplace primary care
● Regular communication and demonstration of senior leadership and management commitment to support a culture of health of safety and health across the organization
● A systems-level approach that coordinates the organizational alignment (i.e., reporting, funding) of traditional safety and environmental health programs, occupational health clinics, behavioral health, workplace health promotion programs, health benefits and compensation and disability management

For more information click on the required reading on TWH at http://www.cdc.gov/niosh/twh/totalhealth.html
Statewide Programs
Maryland Occupational Safety and Health (MOSH) is housed within the Maryland Department of Labor, Licensing and Regulation. Its mission is to promote and assure workplace safety and health and reduce workplace fatalities, injuries and illnesses. MOSH has jurisdiction over all public and private sector workplaces in the state, with the exception federal employees and private sector maritime activities which are covered under OSHA jurisdiction. MOSH focuses on serious hazards and dangerous workplaces; it enforces workplace laws and regulations, conducts inspections, provides consultation services and compliance assistance, offers outreach, education and cooperative programs and maintains statistical data on fatal and non-fatal workplace injuries and illnesses. The MOSH Strategic Plan for 2018-2022 available at https://www.dllr.state.md.us/labor/mosh/moshplan.pdf identifies the following goals:
● Improve workplace safety and health through compliance assistance and enforcement of occupational safety and health regulations
● Promote a safety and health culture through compliance assistance, cooperative programs and strong leadership
● Secure public confidence though excellence in the development and delivery of MOSH programs and services.
For more information on MOSH view the YouTube video at http://www.dllr.state.md.us/labor/mosh/moshvideos.shtml
UNINTENDED INJURIES AND VIOLENCE—MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Unintentional injuries and acts of violence are among the top 15 causes of death in the U.S. Unintentional injury is the leading cause of death for ages 1-44 and the fourth leading cause of mortality in the U.S.
Injury Deaths Compared to Other Leading Causes of Death for Persons Ages 1–44, United States, 2013.
Source: https://www.cdc.gov/injury/wisqars/overview/key_data.html
More than 167,127 deaths from injury occur each year, one person every three minutes.

Source: https://injuryfacts.nsc.org/all-injuries/deaths-by-demographics/top-10-preventable-injuries/

Source: https://www.cdc.gov/injury/wisqars/LeadingCauses.html
Healthy People 2030 identifies injuries are a leading cause of disability for all ages, regardless of sex, race, ethnicity or socioeconomic status. CDC estimates that 2.5 million people are hospitalized and 27 million people are treated in emergency departments for injury each year. Unintentional falls are the leading cause of nonfatal injuries treated in hospital emergency departments and twice as prevalent as the non-fatal injuries that follow including unintentional struck by/against, unintentional overexertion, unintentional motor vehicle accidents.
Violence and injuries extend beyond the injured person to family members, friends co-workers, employers and communities and cost more than $671 billion in medical care and lost productivity each year. Each year in Maryland, more than $200 million in emergency department charges and $835 million in hospitalization charges are incurred as a result of injury.
Sources: Centers for Disease Control and Prevention. (2020). Leading causes of death. Available at https://wisqars-viz.cdc.gov:8006/lcd/home
Maryland Department of Health Preventing injuries in Maryland: A resource for state policy makers. Available at https://phpa.health.maryland.gov/OEHFP/Injury/Documents/MarylandResourceGuide2016HighRes.pdf

Sources: https://www.cdc.gov/injury/wisqars/LeadingCauses.html
Factors that affect unintentional injury and violence:
● Individual behaviors—alcohol use or risk-taking
● Physical environment in the home and community can increase/decrease risk of falls, fire road traffic injuries, drowning and violence
● Access to health services, ranging from prehospital to acute care to rehabilitation, effect the consequences of injuries including death and long-term disability
● Social environment
○ Individual level—social norms, education, victimization history
○ Social relationships—parental monitoring and supervision, peers, family interactions
○ Community environment—cohesion in schools, neighborhoods, communities
○ Societal-level factors—cultural beliefs, attitudes, incentives and disincentives, laws and regulations
Prevention
Violence and injuries can be prevented and their consequences reduced. CDC’s Injury Prevention & Control Center focuses on:
● Addressing Urgent Threats: Adverse Childhood Experiences (ACEs), Drug Overdose, Suicide Prevention
● Preventing Violence: Elder Abuse Prevention, Firearm Violence, Intimate Partner Violence Prevention, Sexual Violence Prevention
● Protecting Youth: Child Abuse & Neglect Prevention, datingMatters, Essentials for Childhood, Youth Violence Prevention
● Preventing Injury: Drowning, Transportation Safety, Older Adult Falls, Traumatic Brain Injury & Concussion
For more information click on https://www.cdc.gov/injury/index.html
The track record for success in prevention of unintentional injury and violence is strong. CDC identifies:
● School-based programs to prevent violence have been shown to cut violent behavior 29% among high school students and 15% across all grade levels.
● Comprehensive graduated drivers licensing programs show reductions of 38% in fatal and 40% in injury crashes among 16 year old drivers
● Seat belts have saved an estimated 255,000 lives between 1975 and 2008.
● Ignition interlocks, or in-car breathalyzers, can reduce the rate of re-arrest among drivers convicted of driving while intoxicated by a median of 67%
Source: Centers for Disease Control and Prevention (CDC). (2016). Saving lives and protecting people from violence and injuries. Available at https://www.cdc.gov/injury/about/index.html
For more information on injury prevention review Healthy People 2030 at https://health.gov/healthypeople/objectives-and-data/browse-objectives/injury-prevention
For more information on violence prevention review Healthy People 2030 at https://health.gov/healthypeople/objectives-and-data/browse-objectives/violence-prevention

International comparison studies show that traffic fatalities can be reduced substantially, if the U.S. begins to focus on scientific evidence when establishing traffic-safety policy. Estimates are as high as 20,000 lives saved each year in the U.S., if road user behavior is modified through sensible traffic laws targeting modest speed reductions and sober driver enforcement. Current studies show that road user behavior is responsible for 94% of crashes and it is not being adequately addressed. In the U.S., emphasis has been on vehicle design and manufacture which account for only 2% of deaths as compared to other countries where road user behavior is the focus.

Traffic fatality changes in the U.S. compared to Great Britain, Canada and Austria
For more information review the required readings on potential traffic fatality reductions:
● Evans, L. (2014). Traffic fatality reductions: United States compared with 25 other countries. American Journal of Public Health, 104(8), 1501-1507. Available at https://www.researchgate.net/publication/263053131_Traffic_Fatality_Reductions_United_States_Compared_With_25_Other_Countries
● Evans, L. (2014). Twenty thousand more Americans killed annually because U.S. traffic safety policy rejects science, American Journal of Public Health, 104(8), 1349-1351. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103206/
UNINTENDED INJURIES AND VIOLENCE—MAGNITUDE OF THE PROBLEM AND PREVENTION
Magnitude of the Problem
Unintentional injuries and acts of violence are among the top 15 causes of death in the U.S. Unintentional injury is the leading cause of death for ages 1-44 and the fourth leading cause of mortality in the U.S.
Injury Deaths Compared to Other Leading Causes of Death for Persons Ages 1–44, United States, 2013.
Source: https://www.cdc.gov/injury/wisqars/overview/key_data.html
More than 167,127 deaths from injury occur each year, one person every three minutes.

Source: https://injuryfacts.nsc.org/all-injuries/deaths-by-demographics/top-10-preventable-injuries/

Traffic fatality changes in the U.S. compared to Great Britain, Canada and Austria
For more information review the required readings on potential traffic fatality reductions:
● Evans, L. (2014). Traffic fatality reductions: United States compared with 25 other countries. American Journal of Public Health, 104(8), 1501-1507. Available at https://www.researchgate.net/publication/263053131_Traffic_Fatality_Reductions_United_States_Compared_With_25_Other_Countries
● Evans, L. (2014). Twenty thousand more Americans killed annually because U.S. traffic safety policy rejects science, American Journal of Public Health, 104(8), 1349-1351. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103206/
Module 13: Critical Issues in Population Health
PRIORITIES AND PARTNERSHIPS
Reducing the leading causes of morbidity and mortality in the U.S. and globally requires a public health rather than a case by case approach.
Recall the 5 Ps: The Public Health Approach = P5
1. Populations

Target for intervention: the country as a whole; a specific state, county, city, neighborhood or specific group such as people at risk or with a particular disease

2. Prevention

Prevention Levels
○ Primary
○ Secondary
○ Tertiary
3. Prevention Strategies

High-risk: focuses on identifying the relatively small number of individuals who are at high risk in order to reduce their risk factor(s) and subsequent development of disease
Population-based: focuses on changing behavior in large numbers of people, most of whom have low or no risk at present, in order to prevent the development of risk factors and disease

4. Partnerships

Activities undertaken within the formal structure of government
Associated efforts of private and voluntary organizations and individuals

5. Priorities

Resources are limited; therefore priorities must be established

6. Public Health Workforce

Assuring a competent public health and personal health care workforce
Given the risk factors and associated health issues highlighted throughout the semester, it is critical to establish priorities, as both financial and manpower resources are limited. Using the Public Health Framework for Priority Setting it is essential to consider the following questions:
● What is the magnitude of the problem?
● Have modifiable risk factors for the problem been identified?
● Does a reduction in the underlying risk factors lessen the magnitude of the problem?
● Have effective strategies for reducing these risk factors been developed?
● How much does it cost to reduce the risk factors?
● Can the program set rigorous goals and objectives and can they be accomplished?
Module 13: Critical Issues in Population Health
NATIONAL PREVENTION STRATEGY
In 2011 the National Prevention, Health Promotion and Public Health Council issued the National Prevention Strategy, a critical component of the Affordable Care Act that establishes priorities to help our country improve its health status. Its vision is:
“Working together to improve the health and quality of life for individuals, families and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness.”
It builds upon evidence from:
● Healthy People 2020
● Guide to Community Preventive Services
● US Preventive Services Task Force
● IOM Reports
● Cochrane Reviews
The National Prevention Strategy prioritizes reducing risk for the five leading causes of premature mortality – heart disease, cancer, chronic lower respiratory diseases, stroke, and unintentional injury. It identifies lost productivity and costs in excess of $1 trillion due to chronic physical and mental illness, which causes Americans to miss 2.5 billion days of work each year.

It focuses on building partnerships among federal, state, tribal and territorial governments; business, industry and other private sector partners; philanthropic organizations; community and faith-based organizations and ordinary citizens to improve health through prevention to create:
● Healthy and Safe Community Environments
● Expand Clinical and Community-based Preventive Services
● Empower People to Make Healthy Choices
● Eliminate of Health Disparities

The National Prevention Strategy has also established 10-year morbidity and mortality objectives for each of the priority areas.
For more information on the National Prevention Strategy, review the required reading:
National Prevention, Health Promotion and Public Health Council. (2011). National Prevention Strategy: America’s Plan for Better Health and Wellness. (pp. 2-13). Available at https://www.hhs.gov/sites/default/files/disease-prevention-wellness-report.pdf
INTEGRATING PRIMARY CARE AND PUBLIC HEALTH
Collaboration and Partnerships
The National Prevention Strategy is grounded in a collective approach to addressing health priorities. It shifts from the conventional model of considering clinical medicine and public health as two separate entities to developing a stronger model that includes an intersection between clinical practice and public heath emphasizing partnerships and collaborations to enhance the health of patients and the public.

The movement toward collaboration and partnerships is taking hold on both the national and international levels. It is being led by health professionals and students across the world and will become one of the prevailing forces in health care in the 21st century. A landmark report on the power of collaboration and the increasing dependence of the clinical and the public health sectors in addressing health problems was issued by the New York Academy of Medicine in 1997.
Click here to review a book review on Medicine & Public Health: The Power of Collaboration.
Watch this video on Primary Care and Public Health to see examples of the powerful results of collaboration.
IOM Reports on a Healthier Future
Interprofessional practice and enhancing the public health infrastructure is the dictate of recent Institute of Medicine (IOM) reports on investing in a healthier future.
Institute of Medicine. (2012). For the Public’s Health: Investing in a Healthier Future. Washington, DC: The National Academies Press.
Institute of Medicine. (2012). Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: The National Academies Press.
Institute of Medicine. (2012). An Integrated Framework for Assessing the Value of Community-Based Prevention. Washington, DC: The National Academies Press.

CDC and deBeaumont Foundation(2015) The Practical Playbook Public Health and Primary Care Together https://global.oup.com/academic/product/the-practical-playbook-9780190222147?cc=us&lang=en&

CDC CDC and deBeaumont Foundation (2019) The Practical Playbook II Building Multisectoral Partnerhips that Work https://debeaumont.org/programs/practical-playbook/

TRANSNATIONAL TRENDS
World health is a priority for all. This is a foundation of the medicine and public health initiative. Many health problems transcend national boundaries and the health status of the populations of all countries directly affects the global economy. Two million people cross international borders every day.
The pace of international travel makes the spread of communicable diseases a priority for everyone. In addition to the current COVID-pandamic, influenza, Avian Flu, SARS, West Nile Virus, STDs, HIV/AIDS, TB and Ebola, vaccine resistance, and antibiotic resistance have alerted the general public to the vulnerability of the population.
Global health is also negatively affected by the spread of toxic and hazardous agents – fumes, asbestos, fire, weapons, banned and illegal substances and the marketing of unhealthy products across national boundaries.
Political changes can dramatically influence the health of a nation. The experience of Afghanistan and Iraq showcase how political change and war influence global economies, negatively affect the health status of populations and change the mindset of generations.
Review the WHO summary in the graphic below.

Click here to view a larger image of the above graphic.
Transnational trends in global health:
● Double burden of communicable and non-communicable diseases
● Population growth and demographic changes
● Environmental degradation
● Globalization of markets with increased free trade
● Increasing urbanization and rural deprivation
● Widening gap between rich and poor
● Continuing reduced opportunity and lower status of women
● Changing nature of community and social support systems and societal democratization
● Development of communication
● Rising aggression, conflicts and human made catastrophes
● Increasing transfer of hazardous work to developing countries
As noted throughout the semester, although health indicators for the U.S. show that our health is generally improving, in too many sectors of the population the health indicators reflect those of many developing countries, particularly among the poor and rural populations.
In terms of the socioeconomic status of the world’s population, over 80% of the world’s population live in nations that collectively possess less than 20% of the world’s wealth and productive capacity. The poorest 40% of the world’s people have less collective wealth than the top 400 wealthiest people in the world. The gap between rich and poor nations is getting wider.
Economic and social development and health improvement are often hard to achieve among the poorest of nations. Inadequate natural resources that have to be shared among too many people, poor planning and misuse of resources, corruption and military turmoil influence the health of many countries.
Key Factors Influencing World Health
Population Growth
The population experienced linear growth until the late 18th century, exponential growth until the 1950s, and remains in a period of hyperexponential growth. In North America, this has been further compounded by migration. Despite advances in technology, the rate will reach a maximum capacity or ecological limit.
Migrations
Migrations have brought people across borders, across continents and from rural to urban environments. At the beginning of the 20th century, 90% of the population was rural. Now, more than 50% is urban. The growth of cities presents a series of complex problems, particularly in developing countries. Water, food supply, sanitary services, fuel and shelter are often inadequate to cope with the numbers. This translates into increased transmission of infectious disease, drug abuse and social unrest.
Health Problems
Many health problems are associated with the interaction of three forces:
● infectious disease, especially among infants and children
● malnutrition
● uncontrolled population growth
One billion serious illnesses each year are a result of common infectious diseases. Each year in Africa, over one million deaths are due to malaria. Three million children die each year of diarrhea, four million from respiratory infections, and three million from vaccine preventable diseases and malnutrition. AIDS cases in Africa alone are in excess of four million.
Industrial development is causing serious environmental damage and occupational diseases. Much of this is by multinational corporations that are assured of a supply of cheap labor, often child labor, and can avoid regulations enacted in developed countries that protect the health of workers and environmental quality. Laws governing worker compensation are often non-existent. Some of the worst health harming habits of industrialized nations, cigarette smoking and traffic injury are becoming increasingly common in developed countries.
How to Enhance Health Status of Developing Nations
A series of problems have been identified that, if addressed, can work to enhance the health status of developing nations.
1. Increase access to health services
○ Preventive services are not a priority– infectious disease remains at an unacceptable level and the health status of women and children, in particular, is poor in many regions
○ Many international health professionals are prepared outside of their home countries and do not return to their home country, of if they do, they return to urban, not rural areas
○ Training programs often emphasize western medicine rather than preventive services
○ Many professionals decide to practice where they can use the skills that they were trained for
○ Restrictions on educational opportunities for women affect the number of trained health professionals
○ The lack of administrators to build health care programs is a compounding problem
2. Invest appropriately in technology
Many high tech tools cannot be maintained or their purchase may not be the best use of scarce resources.
3. Gather health information
It is difficult to ascertain needed services when no system of gathering health information exists. There is a need to set up registries either for whole countries or defined regions. For example, the rates of disease are unknown in many countries. The cancer registry in Jordan was only established in the past twenty years and after the king was diagnosed with cancer.
4. Prevent the breakdown of communication
Telephones, computers, internet connections break down. We saw this with Hurricanes Katrina and Sandy and other environmental disasters in our own country.
5. Make health care a higher priority
Heavy emphasis on military in many developing countries has made health a low priority. Landmines and the consequences of war result in over 400,000 deaths per year, and have dramatically influenced the health of many nations.
All of these trends have major economic, sociocultural, political and environmental consequences that are too large to be satisfactorily addressed by individual countries alone. By combining efforts, transnational health issues can be addressed to shift current global trends to a more positive health outcome
GLOBAL STRATEGIES AND PRIORITIES
World Health Organization

WHO is the lead international organizer in addressing population health. Its Health for All initiative has provided the focus for establishing priorities and inroads for success. Since its inception in the late 1940s, WHO has expanded its focus from the control of communicable diseases to include non-communicable or chronic disease.
WHO directs and coordinates international health through:
● Providing leadership on matters critical to health
● Shaping the health research agenda
● Defining norms and standards for health
● Articulating policy options for health
● Providing technical support and building capacity to monitor health trends
Review the WHO six leadership priorities in the graphic below:

Click here for a larger view of the above graphic
WHO–Communicable Disease Efforts
WHO’s malaria initiatives have become more intensive in the past decade and are mounted worldwide.

Similarly, WHO’s efforts to eliminate TB have escalated.

WHO’s 3 by 5 initiative was one of its first campaigns aimed at getting 3 million people living with HIV/AIDS in developing and middle income countries on antiviral treatment by the end of 2005. It was a major step towards the goal of providing universal access of HIV/AIDS services for all who need them as a human right.

WHO continues to advance the agenda for reducing HIV/AIDs…

…and intensive efforts to address HIV have been strengthened by partnerships with the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Emergency Plan for AIDS Relief, and the UNAIDS initiative. The WHO strategic direction for HIV for 2022-2030 highlights synergies and provides guidance on integrated disease response for HIV, Viral Hepatitis and Sexually Transmitted Infections that is designed to increase efficiency, improve quality, and accelerate progress in eight years.

Source: http://apps.who.int/iris/bitstream/10665/246178/1/WHO-HIV-2016.05-eng.pdf?ua=1
WHO, the United Nations, DHHS and other long-standing international organizations continue to provide leadership in HIV/AIDS by bringing the best research and practice professionals together to share information.

Click on the website and watch the brief video for the 24th International AIDS Conference that highlights the importance of partnerships and evidence-based research in achieving gains in HIV treatment and reduced infections worldwide.
WHO is spearheading the international efforts for the novel COVID-19 pandemic. Addressing this emerging infection has emphasized the importance of understanding the epidemiological triangle, the chain of infection, and how fast a virus can spread and impact the global community. COVID-19 has highlighted the need to use basic public health precautions such as testing, contact-tracing, social distancing, hand washing, and masks to mitigate the impact of a virus that we are continuing to understand and treat COVID-19 has emphasized the urgency of vaccine development and planning mass immunization campaigns as well as establishing herd immunity. The COVID-19 crisis has also showcased the need to plan and prepare for a global response to public health threats, including communication, treatment facilities, equipment, testing, and personal protective equipment (PPE).
The WHO Director General, Dr. Tedro, recently cautioned that we have a long way to go and that there must be a “new normal, a world that is healthier, safer, and better prepared.” For the most updated situation report on COVID-19 click here https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
The map below summarizes the current status of COVID-19 worldwide.

For more information and to search by country click here https://co

vid19.who.int/
WWHO World Health Organization – Non-Communicable Disease Efforts
In the area of chronic diseases, often referred to internationally as non-communicable diseases, WHO has been working to check the double burden of infectious and chronic disease that affects the majority of the world’s population.
Watch this video (6:21) on the WHO global non-communicable disease priorities and partnership network.
WHO has an international mandate for developing and implementing a Global Strategy on Diet, Physical Activity and Health as a leading public health priority.
A few largely preventable risk factors account for most of the world’s disease burden. This reflects a significant change in diet habits and physical activity levels worldwide as a result of industrialization, urbanization, economic development and increasing food market globalization. Recognizing this, WHO has adopted a broad-ranging approach and has developed, under a May 2002 mandate from Member States, a Global Strategy on Diet, Physical Activity and Health, which was endorsed by the May 2004 World Health Assembly.
Source: http://www.who.int/chp/action/en/
A joint WHO/FAO expert report, Diet, Nutrition and the Prevention of Chronic Diseases (2003), examines the scientific data and makes recommendations for the development of regional and national guidelines to reduce the burden of nutrition related diseases: obesity, diabetes, CVD, cancer, osteoporosis and dental disease.

WHO’s Global Action Plan for Prevention of Non-communicable Diseases 2013-2020, which is being update to 2030, focuses on reducing:
“… the preventable and avoidable burden of morbidity, mortality and disability due to noncommunicable diseases by means of multisectoral collaboration and cooperation at national, regional and global levels, so that populations reach the highest attainable standards of health and productivity at every age and those diseases are no longer a barrier to well-being or socio-economic development.”
The Global Action Plan for prevention of Non-Communicable Diseases established focused targets are noted below.

For more information on the WHO Global Action Plan, review the required reading:
World Health Organization (WHO). (2013). Global Action Plan for Prevention of Non-communicable Diseases 2013-2020. (pp. 1-13). Available at https://apps.who.int/iris/bitstream/handle/10665/94384/9789241506236_eng.pdf;sequence=1
On November 21, 2016 the WHO Shanghai Declaration on Health Promotion was issued at the 9th Global Conference on Health Promotion. The declaration commits to make bold political choices for health, emphasizing the connection between health and well-being. Watch this video (2:45) on WHO’s commitment to health promotion.
WHO is developing the implementation roadmap 2023 -2030 for the global action plan for the prevention and control of NCDs 2013-2030. For more information, click on https://www.who.int/teams/noncommunicable-diseases/governance/roadmap
The University of Maryland School of Nursing offers a Global Health Certificate. Click here for more information.

Click here to learn how our faculty and students are creatively and strategically addressing global health problems, and read pages 24-31.
Concluding Comments
In the final analysis, to address any population issue, successful interventions require:
● an awareness that the problem exists
● an understanding of what causes the problem
● a capability to deal with the problem
● a sense of values that the problem matters
● political will to control the problem
The final two steps are often described as redefining the unacceptable, which identifies the ethical foundation of public health.
The miracle of science could and should be shared equally in the world. There is a growing chasm between those of us that are rich, powerful and healthy and those of us who are poor, weak and suffering from preventable diseases. If we are to improve health, we must concentrate on existing disparities to opportunities, resources, education and access to health programs. Only to the extent that we can eliminate these inequalities will our dream for global health in the 21st century be realized.
Jimmy Carter
Critical Issues in Global Health (2002)

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NRSG 780: Health Promotion and Population Health

Paper Guidance and Grading Rubric for Part 1 and Part 2

The paper is divided into two parts. The first section focuses on the content from the first half of the course and the second section focuses on content presented after the midterm. Your paper should follow the rubric and the components should be labeled. Part one (55 points) should include: Overview of the Problem, Review of Epidemiological and Demographic Data and Social Justice Rationale for the Program. Part two (45 points) should include: Goals and Objectives and Program Plan (and its components).

Grading Rubric Part 1:

Part 1 Due March 7, 2022 at 8:00 am

Epidemiology	Possible points	Points
Abstract (only include information on Part 1)	5 points
Overview of the problem	10 points
Review of epidemiologic and demographic data (national, state and local level): · mortality/morbidity · risk factors · health disparities (demographic differences based on race, sex, age, location, income, etc.)	25 points
Social justice rationale for program	10 points
General: 5 pages, APA, grammar, punctuation, spelling Appropriate referencing	5 points
Total	55

Grading Rubric Part 2:

Part 2 Due May, 12 2022 at 11:59 pm

Program:	Possible Points	Points
Abstract (only include information on part 2)	5 points
Goals and objectives	10 points
Program plan including: · program planning model · activities identified to achieve objectives · implementation strategies · behavior/social change framework · collaboration with existing services/organizations · evaluation	25 points
General: 5 pages, APA, grammar, punctuation, spelling Appropriate referencing	5 points
Total:	45

Part 2: Design a population-based program to reduce morbidity/mortality that incorporates appropriate behavior/social change and program planning frameworks.

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NRSG 780: Health Promotion and Population Health Essay